Hi everyone and welcome back. Today I’m here with an incredible human being, an incredible excision surgeon, just incredible person all the way around. So I want to welcome and jump right in. Welcome Dr. Fogelson.

Dr. Nicholas Fogelson (00:15)

thanks so much. Ginger,

I’m really happy that you invited me back to be on the show. think we talked either with you or with someone else with the program a couple of years ago, and it’s great to be back.

Ginger Garner PT, DPT (00:24)

Yeah, thank you so much. So for all of you listening out there, I want to do a little bit of introduction first. Dr. Fogelson is the founder of Northwest Endometriosis and Pelvic Surgery, a gynecologic surgery practice focused on the care of women with endometriosis and other chronic pelvic pain conditions. He regularly performs endometriosis excision surgery.

including complex cases involving the bowel urinary tract and the diaphragm, which we will get into. He’s also one of the few physicians in the US formerly trained in neuro-pelvology or the study of the pelvic nerves and how they interact with pelvic pain, super important, as well as the specific surgical techniques applied to those issues. One of the things I can’t wait to talk about. He is obviously a huge advocate for endometriosis across the world, not just in the US and

Dr. Nicholas Fogelson (01:12)

Absolutely.

Ginger Garner PT, DPT (01:19)

is just constantly doing things like this, like videos, podcasts, writing, as well as frequent presentations all over the place, national and international. So welcome.

Dr. Nicholas Fogelson (01:32)

Thanks very much for

inviting me and I look forward to having a good discussion.

Ginger Garner PT, DPT (01:36)

Yeah. Okay, so.

First question was perusing, because I obviously follow you on Instagram. And you have the obvious things. Go, go now, go now. All right, so you have expert endometriosis surgeon, yes, check that box, in Portland, Oregon, by the way, everyone, complex cases, bowel, thoracic, abdominal wall, neuro-palliology certified, and a LEGO enthusiast.

Dr. Nicholas Fogelson (01:50)

If anyone’s listening and they’re not following me on Instagram, go follow them.

I am, yeah. used to be… Well, there’s a… Got a few back there. R2 is missing a head. R2 needs a head. There’s an International Space Station there. This is the best LEGO set ever designed in history, which is the collector’s edition A-Wing, which is a Star Wars ship that has a very unusual shape that you would think would be impossible to make in LEGO because it’s not symmetric. Like, LEGO has to be in…

Ginger Garner PT, DPT (02:12)

I’m really curious about the last one.

my gosh.

Nice.

Yeah.

Dr. Nicholas Fogelson (02:38)

Even numbers, it’s hard to make something that is an odd number of bricks wide and have it be, but there’s stuff going down the direct middle of a thing that has an odd number of bricks in its width. So the inside of it is bizarrely constructed to create that shape. it’s when you build it, if you’re, you’re in the Lego and you build it, you’re just like, Oh my F and God, how did they figure this out? Because it seems impossible to create that shape. yet they did. You have to make curves out of. You know, you making curved things out of.

Ginger Garner PT, DPT (02:42)

Yeah.

You

Yeah, well, I have

Dr. Nicholas Fogelson (03:08)

square connections mostly.

Ginger Garner PT, DPT (03:10)

Right, right. Yeah, well, I have three boys and three kids, and I’ve done my fair share of Legos. In fact, we built Helms Deep once.

Dr. Nicholas Fogelson (03:20)

that’s a good, the big one or the little one? yeah, that’s awesome.

Ginger Garner PT, DPT (03:22)

The big one. Like

my hands go way outside. Yeah. Yeah.

Dr. Nicholas Fogelson (03:27)

Yeah, that’s a, that’s an amazing set. But if you’re

going to, if you’re going to talk about Lego, we have more than one Lego. They’re just Lego. There’s no Legos.

Ginger Garner PT, DPT (03:34)

And that’s… Yeah, yeah, my gosh. All right, so yeah, I was wondering about that. That’s gotta contribute some like work-life balance because…

Dr. Nicholas Fogelson (03:38)

Otherwise people go like, gosh.

Yeah,

I used to be into it a lot. still am somewhat, but I have other interests as well, but I’m a geek. You know, I like, I’ve got Dr. Strange up there also. The patient gave me, gave me that interesting story, but, but yeah.

Ginger Garner PT, DPT (03:58)

Aww yeah.

Yeah.

Well, you are so incredibly busy and in addition to the Lego thing, here you are conquering the world and helping with this entire issue of Endo awareness and what’s happening and helping people get the right care. so I wanted to segue into that and just

ask about because for the listener, they may have never heard of some of the concepts that particularly your certification in neuropelviology If from that perspective, can you explain how that field enhances the diagnosis treatment of complex pain conditions?

Dr. Nicholas Fogelson (04:48)

Yeah, absolutely.

so it’s neuro-pelviology is kind of got an E in there, they do. Yeah. it’s, French. it’s so they say the, so, neuro-pelviology is a field that it was sort of coined by Mark Passover, who’s a French surgeon who now, now practices in Switzerland. And he started doing.

Ginger Garner PT, DPT (04:53)

Ooh, they pronounced the E, okay.

Dr. Nicholas Fogelson (05:16)

sort of that area for about 10 years in developing techniques and some theories on it. And once it became clear to him that he was on the right track, he started offering to educate other doctors. And now it’s kind of grown to where there’s an international society of neuro-pelvioology. It’s almost all in Europe and Africa. And there’s not a lot of Americans that have gotten involved, more South American, Brazilian, and then European. Only just a handful of US people are level one certified. And I think I’m the only level two certified.

except for Jan Eynersen also, but he’s mostly practices in Iceland now. what neuro-pelviology is, I like to say it’s everything that I ever forgot about neurology that I relearned. Like it’s not, it’s not stuff that people don’t know. It’s stuff that people knew and then forgot. Because when you are in your second year of medical school, you’re going to spend eight, 10 weeks on, usually you’re only doing a couple of subjects at a time.

You’re to have an eight or 10 week block on a pelvic, on neuro function. And that’s going to be the brain and the spinal cord and all the nerves. And everything that is in neuro-pelviology is kind of a subset of those things that you learn when you learn neurophysiology as a medical student. But you inherently in medical school really study topics really deeply and gain mastery of them. And then you, you know, like anything, like in college, you study for a test and you take the test and then.

If you don’t use that material, you’re probably going to forget it. And so if you don’t become a neurosurgeon or neurologist, you’re probably going to forget it. so neuro-pelviology is kind of relearning how the spinal cord works, how the somatic nerves work, how the visceral nerves work, how different organs in the pelvis are innervated, both efferently, which means nerve signals going from the brain away, and afferently, which means signals going from further away to the brain. So efferent is out, afferent is in.

And so there are both visceral and somatic afferent and efferent nerve pathways. by understanding very clearly what those nerve pathways are and what each function is, you will come to understand different ideas on how you might help someone. I’ll give you an example. I have a patient that contacted me just a couple of days ago and she’s got intractable constipation and her colon, she had a previous big endometriosis excision surgery by another surgeon.

And I don’t think that surgery really had anything to do with this problem. actually had this problem before the, before the endometriosis surgery. So I’m not laying it at the feet of the other surgeon, but basically. The left, her colon, she’s unable to defecate without tremendous amounts of, laxatives and her, her bowel studies basically show that poop moves through her colon from the cecum all the way up to the splenic flexor, which is up on the left side.

And then the food just stops and it stops moving. And her colorectal surgeon, she saw like six different colorectal surgeons and they said that she just needs a total colectomy. So take out the whole colon because it’s not working and we’ll do it. We’ll do an ileostomy or do a ileo rectal and osmosis for they pull a small bowel down to the rectum and there won’t be a colon and she will either have diarrhea or shall have a bag for the rest of her life. Well,

I look at that from my neuro-pelviology point of view and I told her, a lot of people call me and I can’t always fix the problem, but sometimes I know stuff that other people didn’t know. And I said, well, the reality is that your colon’s two different organs. From the cecum up to the splenic flexure, it’s innervated by the vagus nerve and from the splenic flexure down to the rectum, it’s innervated by parasympathetics in the pelvis. And when you have everything moving until it gets to the splenic flexure, what that means is that the pelvic parasympathetics are not working.

And that part of the colon is de-innervated, but the rest of the colon works fine because it’s innervated by the vagus nerve. And then I called this real smart gastroenterologist that, excuse me, a colorectal surgeon I know named Paul Kaminsky. And I say, and she’d gone to the Mayo and she’d gone to, to, to Cleveland clinic. And I’m going, don’t people know this neurology? Like, why would you take out her whole colon? You just have to take out from the splenic flexor down and you can pull the transverse colon down because that part works. And they go like, honestly, I didn’t even know, or is it like, no, they don’t, they don’t know that.

Ginger Garner PT, DPT (09:30)

Mm-hmm. Mm-hmm. Yeah.

Dr. Nicholas Fogelson (09:35)

Like that’s not something they know, that

Ginger Garner PT, DPT (09:35)

Yeah. Yeah.

Dr. Nicholas Fogelson (09:37)

colorectal surgeons are gonna routinely know. And so, and I didn’t know that before I studied neuro-pelviology and I didn’t know if colorectal surgeons do that, but like that’s something that I knew about the colon that the colorectal surgeons didn’t even know. And when this patient called me, I’m like, don’t take out your whole colon, two thirds of it works fine. I said, it’s the distal part that doesn’t work. And I don’t know how to make it work. I’m not sure if there’s any way to make it work.

But if you’re going to have a bowel resection, I’m 99 % sure that you could just take out this half of it and the rest is going to work. And you’d save, you’d still be able to collect water through the rest. And so she might fly out to see my colleague and have him do it. I don’t know. I don’t know what’ll happen with that, but you know, a lot of times patients call me with unusual things and I’m just a really curious doctor. I’m not scared by mysteries and I’m kind of curious. Like when I think of run into something I don’t understand.

I try to figure it out and I’m not afraid to paint outside the lines when it comes to what gynecology is. Like lot of my knowledge set is outside of what is traditional gynecology and I’m not really afraid to have an opinion. I think that some people would say like, you’re a gynecologist, how can you have an opinion about colorectal surgery? And I’m like, well, neurology is neurology. Like I know how the nerves of the colon work. Like my opinion is valid. know, it’s for a reason, specific reason.

You should tell me why I’m wrong. If you think I’m wrong, because I’m giving you a very specific, physiologic reason why I believe what I believe. And, and that their reason is, Oh, take out half the colon. Doesn’t work half the time. It only, they say that what she was told is it only works half the time. I’m like, yeah, cause it only works in the half the people that have that problem. That when something I’m getting off of your question, but when, when people say that X technique works half the time, I always say, no, it works a hundred percent of time in half the people.

Ginger Garner PT, DPT (11:14)

Mm.

Dr. Nicholas Fogelson (11:28)

And, that’s not the same thing. That’s not the same thing as saying a technique is 50 % effective. You have to identify the 50 % of the people, the technique are going to work for, and then it’s going to work for them. And so if we can get better at identifying who will benefit from different things, then we can be more successful at whatever we’re doing. And we can be really, really good at our physical technique, but identifying who’s going to benefit from what things is where your success rate is really going to come up with. But so.

In any event, so neuro-pelviology, that was just an example where understanding the pelvic nerves and the abdominal nerves and not just pelvic, like, I mean, I’ve learned a lot about spinal cord all the way up to the brain and everything starts to give you a different perspective on what you might do. Um, I had a patient that had, uh, cyclic pain in her epigastrium that was horrible. Every time she had a menstrual cycle, she had a horrible, horrible pain. And people said she was having estrogen related gastritis and that she was having.

estrogen related gall, gallstone attacks or something, except she didn’t have gallstones in her inside of her colon. Stomach looked fine on endoscopy, but no one could come out with any other answers. So they were giving her all kinds of bullsh*t answers. And, um, she had been scoped and somebody looked in an urin and didn’t, had endometriosis, but, but no one saw anything else. She came to see me and I said, the epigastrium is the referred source for a right colon. That’s where the, the, the, the visceral innervation of the right colon is going to come up.

into the celiac plexus and you’re going to feel pain because we feel visceral pain at the plexus where the signal enters the spinal cord. So visceral pain is not felt in the organ. It’s felt in the center of your pelvis or center of your body somewhere along the center where, where that signal enters the spinal cord. And so if she’s having cyclic pain that seems like endometriosis and it’s in this location, well, it’s got to be in her right colon somewhere. So I went and scoped her and she had this huge fist size mass of endometriosis in her cecum that

a previous surgeon had looked at and not recognized. And not surprisingly, because it didn’t look that abnormal, but I knew what I was looking for. And it looked a little bit abnormal. And we did ileocectomy and she had this like plum sized tumor and she was cured. it was like, and it’s hard to image too, like on an MRI, it’s not always going to show up very well. So like there are times when having that specialized knowledge and sort of a different way of thinking about stuff leads us to make diagnoses that maybe other doctors didn’t pick up on.

You I, I hate to ever say like, I’m smarter than anybody else. I’m not. just, you just gather this, having more information to work with will often lead to the right answer. so sometimes, sometimes we’re able to fix some people that other people weren’t able to fix. that feels great. Like that’s why I do it. You know, it’s why I studied because I, I hate it when somebody comes in and you’re just like, you know what? don’t know how to help you. I’m sorry.

The more you know, the less often that happens.

Ginger Garner PT, DPT (14:26)

Yeah. Well, thank you for walking the listener through that and how they would know if there’s any other tips that you can give them about how they would know what complex pelvic pain feels like, especially in regards to the sacral nerves and the pelvic nerves, that kind of thing.

how would they know, but since you have your level two certified, obviously that would be a great idea is for them to come see you. What would be some of those indications for them?

Dr. Nicholas Fogelson (14:55)

Sometimes.

Well, one of the really…

I always try to just temper expectations a little bit. I mean, I’m not, I’m not the wizard of Oz. Like, like I can’t, and even he wasn’t obviously, but the, you know, there are certain things I’ve had a lot of success with, but there are still cases that I have trouble with. I don’t want to create this expectation that I can fix everyone because I can’t, but there’s definitely some that I have succeeded with that other people have not. so.

Ginger Garner PT, DPT (15:11)

Yeah

Dr. Nicholas Fogelson (15:29)

There’s two different classifications of pain that are, I think are important to kind of separate things. have visceral pain. Visceral pain is dull, aching pain generally felt in the midline of the ab, anywhere from the bottom of the tailbone up to the chest. But it’s going to be dull, aching pain that is hard to localize. Usually people are going to put their hand like this or in their belly and they’re going to say it’s like this generalized. Like someone’s having a heart attack. They have crushing pain in their chest. That’s.

visceral pain. So when people have visceral pains, it means that the visceral nerves are irritated. So either there is disease in the organ itself, such as the woman that had endometriosis in the wall of her cecum, or she has endometriosis in her appendix, or someone has endometriosis in the bladder wall, or something in the rectal wall, if we’re dealing with Endo. Or there is something inflaming the nerve pathways that

are along the way. So you can either have disease state in the organ or you can have some disease state that’s kind of along the highway up to the spinal cord where that is irritating it and giving you the perception of having bladder pain when it’s really the nerves coming from the bladder that are irritated. So that’s visceral pain. That’s a common thing we see in endometriosis because the pelvis is all kind of pretty close together. And if you have endometriosis, say in the uterine sacral ligaments,

The hypogastric nerve plexus is just a centimeter or less away from that. And so if you have a lot of inflammation, the nerve plexus is going to be irritated. And when that signal, this sort of disordered signal is coming up, you’re going to get bladder spasticity. You’re going to get bladder pain. You’re going to get urgency. You’re going to get rectal pain. You’re going get uterine pain. And those organs may be healthy. It may just be that the pathway is messed up. And so that’s going to be characterized as dull aching pain.

And when you have dull licking pain that is cyclic with your menstrual cycle, you start thinking, well, I have some sort of probably endometriosis or hormonally responsive injury to the visceral nerve system for some reason. And then you’re to get into more details about exactly what we think that might be. And then there are somatic pain. So somatic pains and somatic feeling is what we consider to be feeling. if I’m holding my pencil and I perceive the pencil in my hand, that’s a somatic sensation.

If touching your finger or your face or any part of our body where we can identify very specifically where the sensation is coming from, that is a somatic pain. That is not being carried by the visceral nerves. It’s being carried through the ventral roots of the spinal cord roots. So like L4, L5, S1, S2, S3. So these are all the roots of their myelinated nerves, very high speed nerve connections that are highly myelinated, which makes the nerve signal.

travel very fast. It’s like if you touch a hot coal, you’re going to jerk back really fast because the nerve signal get to your spinal cord very, very fast. and those kinds of pains are, are almost either because of an injury where you’re feeling the pain. For example, if you stub your toe and your toe hurts, well, you’ve injured the nerve ending in your toe and it’s created that, that visceral or excuse me, somatic pain in the toe. But also if you.

injure a nerve, somatic nerve, you will feel pain at the distal or the far distribution of that nerve. So if I have an injury to my second sacral nerve root on the left side, or I have inflammation in my second sacral nerve root, I’m not going to feel pain in my pelvis. I’m going to feel pain on the bottom of my foot. And I’m going to feel pain down the, down the back of my leg towards the inside. And I might feel pain into my rectum because of some pudendal branches too. So.

the pain is gonna radiate out. And so you could kind of think of like the end of it as being like the light bulb and the nerve is the electrical cord. And so the electrical cord is getting turned on by the signal and the light bulb is turning on down at the end of that. And so when a patient says, have sharp shooting pains, I always say, well, shooting from where to where. And I always ask patients to be very, very specific. And a lot of times people wanna be general and I say, no, no, no. And they wanna go on to something else real quick. I’m like, no, no, tell me more about that.

Ginger Garner PT, DPT (19:51)

Thank

Dr. Nicholas Fogelson (19:53)

And I want to know exactly what you’re feeling. And we’re going to talk about where it’s coming from. And we try to understand very quickly, is it visceral or is it somatic? And then they go, okay, or is it a combination? And then where is it going? And then you can understand what nerves are carrying this pain signal. And then you can try to make it with a bunch of information put together and try to come up with some idea of why the patient’s feeling that.

And again, there are times where this leads us to different answers than just go in and cut out the endometriosis is a very general kind of thing. Like a lot of surgeons are good at doing that. I’m good at doing that. But certainly some people go, well, we go to the OR and we cut out all the endometriosis without like a really clear thought process about why the patient’s feeling what they’re feeling necessarily. And there are times where I say, well, in this patient, actually wanted to sect out the obturator nerve and I wanted to sect out the sciatic nerve because they have this specific

symptomatology and I think I might find something. And you, you find out that it’s not always just endometriosis. There’s other things that can cause somatic nerve pains. Piriformis syndrome, which is where the, sometimes there’s a portion of a nerve root is traversing through the piriformis muscle. And when that muscle gets into spasm, the nerve root is getting irritated. There can be also vascular compressions where

which has now become kind of published enough that it has a name, we call it superior gluteal vein syndrome. And that’s usually where the sciatic nerve or the lumbosacral trunk is getting compressed between the superior gluteal vein or branches on the superior gluteal vein and the sacrum. And in some patients, there will be a tight band of vein that’s right over the top of the sciatic nerve and you can go in there and you can see it and it’s literally like.

creating a divot in the nerve, like you see the vein just tightly around the nerve. And when that vein’s getting around a blood flow, the patient gets sciatica. And the answer to that is to go in and operate and find that vein and just seal it and cut it. just sometimes it just, you just cut it and it just like pops open because it’s under tension in the nerve. And then you’ll see the sciatic nerve and the veins like kind of compressed on it. And then you pop the pops up and the nerve goes, like the nerve like clearly was under some compression. And

So those are some cases that I’m going to deal with that most people are not. but you have to kind of understand who would you do that on? you know, that’s a, you know, particular symptomatology. So, and it’s hard to explain all of it, but I mean, there are a variety of things like, like vascular issues are usually worse when you’re standing up. It’s also kind of interesting that people with vascular cyclic pain that is

going with their menstrual cycle that is vascular gets much, much worse coming up into the menstrual cycle. Like as they get ready to have their menstrual cycle, they’re having worse, worse, worse pain. But as soon as they start bleeding, they feel much better. And they say, my God, I can’t wait to get my menstrual cycle. finally feel better. As opposed to endometriosis and irritating somatic nerves, that causes worsening pain leading into the cycle. And usually it gets much worse as they start bleeding.

Ginger Garner PT, DPT (22:53)

Mm-hmm. Mm-hmm.

Mm-hmm.

Dr. Nicholas Fogelson (23:10)

and the first two, three days of the bleeding is very, very painful. That is more related to endometriosis, whereas if they feel relief when they start bleeding, that is more suggestive of some sort of somatic vascular compression. so again, like teasing out these, asking the right questions and teasing out these details can lead us to more specific ideas why someone is in pain rather than just, they have endometriosis, let’s go cut it out. Because as effective as endometriosis excision is, and it is,

a pretty effective technique, there are definitely people that have persistent pain and some of them are a mystery, but some of them are not. Like some of them have other stuff going on that just isn’t endometriosis and you can sometimes intervene with it.

Ginger Garner PT, DPT (23:55)

Yeah, yeah. So what inspired you to specialize in endometriosis? Yeah. Both. mean, we probably, you know, listening understand why the latter because of the complexity of the pelvic nerves and, you know, the interaction with the vascular structures and stuff. That makes it so clear as to why you would pursue this additional training.

Dr. Nicholas Fogelson (24:03)

in, in gynecology and endometriosis and what.

I I pursued it because I was just kind of, you know, when I was a general OBGYN, I was unsatisfied with like the level of care I was able to provide. Like I thought I was good at what I did from the level of training, but I was like, you know what? I, I’m not as good as I want to be. So that led me to go do a fellowship. I’m just personally driven to just be as good as, as good as I can possibly be at whatever I’m doing and to not be interested in doing stuff that I’m not good at. Like.

I had someone that came in that needs a sling for incontinence and she clearly needs it. It’s like, I know how to do it. I’ve done it before, but I still told her, I I’m not going to do that. Like there are people that put in hundreds of slings a year and yeah, I know how to do it. But if my wife needed a sling, I wouldn’t tell them me to do it. I would tell them to go see a uroganicologist. So I’m going to do her endometriosis surgery and either we’ll get some party to come in and do the sling during my surgery or she can get a sling done at some other time. Like.

I’m not interested in doing something that I can’t be really, really, really good at. And if I’m not really good at it, want to get, and I want to do it. I want to become really good at it. And that’s just my personality. Like I’m very narrow. I get, I get very, I mean, I’m slightly autistic and like I have Asperger’s. So like part of that is, getting very, very focused into things. Like I find certain things that like I’m just

incredibly, incredibly fascinated by, and I want to get really, really deep into. And when there are things that are going to, that I’m not going to be able to come really good at, I kind of lose interest. like, well, I’m never going to be very good at that. I would rather spend more time on the thing that I’m going to get even better at. That’s just my personality. So, so I wanted to get better. I, I was aware, you know, as a general OBGYN that patients with pelvic pain just, just.

were getting poor care. And I mean, I wasn’t even aware it was poor care. just, they just weren’t getting better. You know, it was just a sense of, well, they’re hopeless, go scope them. Maybe you find some endometriosis. There’s not much you can do. Put them on birth control pills and, you know, eventually take their uterus out. And if it doesn’t work well, at least they don’t have any organs anymore. And you can refer them to psychiatry. You know, like I was taught that. mean, that was what I was taught, you know? So, but

I just wasn’t satisfied with that. And I was aware of people that were doing it better. And so I kind of looked at what are they doing and you know, they were generally doing endometriosis excision. And this was, this was in the nineties or late nineties. And I was kind of aware of it, but it was way over my head as far as being good at it. that point, laparoscopy was still something that was, you know, still developing.

Like high level laparoscopy was still developing. There was really very few people in the country that were like really, really good laparoscopists at that point. And I was not, I was, I would say good for my level of training and experience, but I was nothing like I am now. And, and so I decided to do a fellowship. I said, okay, I’m not going to get better continuing to be a general OBGYN delivering babies. And, and being in the operating room with no mentors, like I was one of the best surgeons in my department. thought, but it was like.

There was nobody that was substantially better than me that was going to make me better. And, and so I’m either going to stay what I consider to be mediocre at that stuff, or I’m going to get more training. And so I went into a fellowship at Emory. I did a cancer fellowship. wasn’t an MIS fellowship, which I I’m really glad for because they had like an advanced pelvic surgery fellowship, but it was really oncology that the, was within the oncology division.

of the OBGYN department at Emory. And they didn’t have a credited G1 oncology fellowship because they didn’t have the research infrastructure for that particular thing. So their oncology fellowship was called the Pelvic Surgery Fellowship and he didn’t come out as a G1 oncologist. A lot of the people that were there were there because they didn’t match in G1 oncology and they wanted to do something for a year before they reapplied for G1 oncology. But in my case, I went there and I did cancer surgery every day for a year.

And it was great. mean, I just operated three, four, five days a week. I was also, it already been out for six years. So I was able to be in attending. I wasn’t really a resident anymore. Like most fellows are like advanced residents where I was, I’d already been attending for six years. So I was able to interact with, you know, the other, the other residents and stuff, as more as an attending, which was a different kind of relationship. And,

Just got to do everything I wanted to do.

so I got to just do really, really complicated cases with the mentorship of people that could make me better. And, know, I did cervical cancer and ovarian cancer and endometrial cancer and no dissections and all the stuff that is just the building blocks of anatomy and good technique. And then I didn’t really get taught endometriosis surgery. I got taught anatomy and I got taught technique and, then I learned endometriosis surgery by watching.

Other people do it. mean, I kind of understood what I was trying to accomplish, but I understood that I started to understand the anatomy well enough to, to grow what I was doing. And I was doing it while I was a fellow. And then I stayed at Emory and continued to do it. And I, you know, I’ll admit I wasn’t that good at it back then. Like I, I had success with some of the cases, but I mean, I, go back and look at those videos and I’m like, God, I mean, I’m. I think every endometriosis surgeon has gone through that period.

You don’t just go from wanting to be an endometriosis surgeon to being really good at it overnight. I I feel like it took me about at least five years and almost like 10 years before the learning curve was flattening out. it just takes a lot of time and it takes a lot of sort of going a little further, a little further, a little further where, know, you kind of reach the point of your, your fear and your, your anxiety about what you’re doing.

to work, because you don’t want to hurt a patient, you know? And so when you get to the edge of what you feel comfortable with, some people kind of quit and don’t do everything because they’re like, OK, I’m going to I’m going to have a heart attack. need to quit. You know, and but the more and more you you do, the further and further you can get comfortably. And eventually you reach a point where you’re just doing really complicated cases while you’re listening to music and talking with your colleagues like it just no longer becomes a big deal. But it took a long time. And and

So I did all that and then, and now that’s what I do. And I’m really, you know, it’s exciting to do it and it’s exciting to have success with a lot of patients. You know, we have a lot of patients that do really well. It’s still a really difficult disease state. I’ve sort of said this already, but I mean, like I always hesitate to paint myself as some sort of magic worker because it’s a really difficult disease state. And.

We can do really good things that can be helpful, but it’s still, you know, I wish there were things even better than what I can do, to be honest.

Ginger Garner PT, DPT (31:28)

Yeah, well think that this sharing your story just impacted me so much because I think it’s the hallmark of a good clinician in any realm, Whether it’s therapy or surgery or whatever it is, to do that kind of review, look back and see where you’ve come from and to look ahead and see where you want to go with it. And I’ve got a question based on that, but before I ask that question, I wanna ask this one.

is can you describe a few of the challenging cases that you’ve encountered with excision surgery and how do you navigate those complexities and you mentioned calling someone else in or whatnot.

Dr. Nicholas Fogelson (32:10)

Sure, I mean…

Yeah, I mean,

I don’t call people in like, I have colleagues that do certain elements of things. I don’t ever call someone in like, because I can’t handle something as much as like, I call someone in because there’s a certain part of this surgery that someone else should do. There was a time when I did, like when I was a fellow, sometimes I called my chair and just said, hey, this case is freaking me out. Can you come and help me? Like, but that doesn’t happen anymore. But it does, but technical parts like, okay, so today I did a

Ginger Garner PT, DPT (32:26)

Yeah. Yeah.

Dr. Nicholas Fogelson (32:44)

a real, we had a really challenging diaphragmatic endometriosis surgery and the patient had, that’s why I was late. I mean, we started at 7 30, we didn’t finish like one 30 and the patient had really severe disease. She had had a surgery, stage four endometriosis surgery with a colon resection by a good excision surgeon. And, but he had noted endometriosis in the diaphragm and knew it wasn’t for him. And he didn’t do anything with it, which is great. And the patient came to see me and she had disease invading.

Not only through the anterior diaphragm, but also through the posterior diaphragm behind the liver where a lot of people don’t even know how to get there. And we dissected all the way under the liver, lifted up, saw the vena cava, like had a whole vena cava hepatic vein exposed. And we ended up stapling off a big portion of the posterior diaphragm. and then stapled and then cut into the pericardium or not the pericardium, but into the mediastinum. Like we could see the pericardium right there.

and repaired that and then took some more diaphragm from the left.

That technique, and so I involved Jeff Watkins, who’s a, in fact, he did a lot of it. I mean, he’s a foregut surgeon and, and, foregut surgeons operate in the chest all the time. do esophagus and they do people that have like esophageal cancer. They would go and see a foregut surgeon. So that, that specialization is actually perfect for diaphragmatic endometriosis because they’re in the chest all the time and they understand how to access that area.

Like the stuff we did with mobilizing the liver, like I’ve never seen anybody do that stuff until Jeff and I, Jeff explained to me how to do it because he knew how to do it in order to get up to the esophagus and how to, and how to do the stuff that he does. And when I got to start working with him and we started doing diaphragm work and I would see disease behind the liver and I’m like, I don’t entirely, I see it there, but I don’t entirely know how to get there. And then he goes, let me show you how to do that. And we, you know, have the liver like flopped over where.

where you have just incredible exposure. Well, that’s not gynecology, that’s like liver surgery, you know, but you can’t call in the hepatobiliary surgeon to come help you because they’re busy doing something else and they’re like, what the F are you doing? You know, so you have to develop these partnerships. So like I have this great relationship with this Jeff Watkins and then a couple, you some other people as well, like Carrie Wickham and Paul Kaminsky and Sabrina Drexel and each one of them have…

Ginger Garner PT, DPT (34:43)

Yeah. Yeah.

Dr. Nicholas Fogelson (35:06)

You know, lanes that they’re in, like Jeff is my thoracic’s foreguts guy. And then Drexel has done a hernia fellowship. So she helps me with lot of hernia stuff. And then Kaminsky is a colorectal and, and Wickham is a colorectal and Jeff does Collins too. So it’s like, I know who, who to work with for who. And we just have a great team that is, you know, they’re available to me, which is awesome because I refer them cases and in private practice, that’s, that’s the, that’s the bread and butter. You want cases and yet, and so.

Like that’s an interesting case. And I’m like, this is a really advanced diaphragmatic case that I guarantee nobody can do better. Like we really did it nicely and hopefully the patient does, she’s just coming out of the OR. So, I mean, hopefully she does really well, but, you know, technically it was really nice. So, you know, and then we do a lot of, you know, we develop techniques for doing colons where we, you know, we never open anybody to do colon surgery anymore. Where we either, if we’re doing a hysterectomy, we can do it all transvaginally like any.

Any stuff you need to come in and out can be done transvaginally. And now we’ve modified techniques that are in colorectal surgery that they use for diverticulitis. And we do transanal cases in patients that are preserving their uterus and there’s no big hole to get things in and out of. We do it all transanally. we’ve literally, because we’re removing a piece of the colon, you can develop an open channel between the anus and the inside of the belly. And then you…

literally can remove a piece of the colon, pull it out through their bottom and then make the asthmosis. So it makes a huge difference for patients to do those kinds of techniques. And what I found in academia is that people don’t want to do that stuff because it’s like, we want to teach just like the straight, basic way to do this to our fellows. We don’t want to start doing these acrobatic things because A, they’re still learning. You know, if they say they do that on their boards, the

board examiner’s gonna criticize them. It’s like, oh, why are you doing that? But now that we’re free to just sort of do what we wanna do and find out what we think is the best for our patients, I think that we’ve taken it to a great level because the level of, you have, for example, a colon resection, if you can avoid making an eight or 10 centimeter incision in the patient’s belly, I mean, not necessarily even that big, but say a four centimeter incision for bringing your staplers in and out, it makes a huge difference in the patient’s recovery.

to have their abdominal wall intact, like you haven’t ever cut into their abdominal wall other than like some eight millimeter holes. And we routinely, yeah, and we routinely do that and patients do really, really well. And furthermore, like we almost never do ostomies. That’s not to say that ostomies aren’t appropriate in some situations they are, but again, you get back to kind of traditionally taught colorectal surgeons, much more likely to pull up ileostomies doing colon intersections because

Ginger Garner PT, DPT (37:36)

Yeah, it’s easier for PT too after.

Dr. Nicholas Fogelson (38:01)

their data says that like, especially if they’re older, like the colorectal surgeon, the people I work with are generally kind of younger and, and we just don’t, our philosophy is like, why would you, well, in general, why are you going to divert someone to avoid diverting them? Because if they leak, you’re going to divert them, you know? And so we’re going to divert. If we, if we’re going to leak two out of a hundred cases, are we going to divert a hundred people to avoid diverting two people? It doesn’t make sense.

And yet, and yet the sometimes the tried and true like board, colorectal surgery board answer is you should divert if their X criteria are met. And yes, we do divert occasional applications that are really, really high risk, but we’re very willing to push the limits on that because we know that having the liostomy sucks and patients don’t want to be pooping into a bag if they can avoid it. And we can monitor the patient. We can do a, we can do a fairly lower nastimosis if we need to, and we can

put the patient in the hospital and check labs every 12 hours and we can come check on them a couple of times a day. And you know, if something starts turning badly, we can get a CAT scan. if there’s a problem, well, then we can divert them, you know, and it’s not, it’s not going to be a disaster. Like if that happens, it’s not going to be a disaster. For people that don’t, I may have been talking about stuff that they don’t understand. So diversion, when you do a colon resection, diversion is where you bring a loop of bowel up to the skin and you have a

an ostomy and you have the stool coming out into a bag. And the reason why you would do that is that you have a part of the colon that’s healing. And some philosophy would say that having the stool, which is dirty, mean, it’s full of bacteria, going by that healing place is bad and that it’s more likely to leak if it’s not diverted. And I think that it turns out that’s not really true. That as long as the nyastemosis has good blood supply and it’s a good connection and the staplers.

operating correctly, we usually staple them. don’t see each of them pretty much ever. then it’s going to hold together and the patient, and furthermore, the patient actually does, there, there is an effect of enteral feeding. Like we used to believe that you shouldn’t feed people after bowel surgery until the bowels working again. I think we know now fairly clearly that actually you should feed them and that the bowel itself is fed by the food. And whereas a lot of

parts of the body are picking up nutrients through the colon, through the bowel, and then spreading it out, that actually the bowel cells themselves are being fed by the food in the bowel. And so by starving the bowel of food, you’re actually impeding good wound healing. And so now we believe that you should feed people as soon as feasible, and we don’t restrict people from eating after bowel resections, you know, in most cases. So a lot of little things, we just keep advancing what we’re doing.

Ginger Garner PT, DPT (40:51)

Yeah,

that’s a, you actually answered my next question already. So, because it was about sigmoid, colon, rectal area, all of those things that patients when they do know they have bowel endometriosis or they think that they do and they’ve had a long standing struggle with GI issues are terrified of what could happen. And I think that your answer was just amazing at how things are shifting and evolving and how far they’ve come.

Dr. Nicholas Fogelson (41:20)

Patients do well. Like I used to be pretty, I was, when I was getting into this, I was a little more conservative, particularly when I was in fellowship because my, my mentor was always discouraging me from doing stuff. Part of why I left Emory actually is I felt like they were discouraging me from doing stuff I wanted to do that I thought was right. And they were too traditional and not willing to go, go the distance. I thought. And so there was a time where I was more conservative. Like when I saw.

some bowel disease that I wasn’t sure how bad it would be. We like, don’t remove it. We remove a whole bunch of endo, all the endo, and then we, okay, we’ll see how the patient does. It’s like what I’ve found over the years, and you know, my experience keeps evolving, is that that doesn’t work. That if you see bowel disease, on the large bowel, not necessarily, and again, not every case is different. I’ve had some patients that had bowel disease that I didn’t remove, and I told them it was the right answer. So don’t, if you’re that patient, don’t.

Don’t think that I changed my mind. Like there are cases where I leave it, but in general, if you see significant disease, the patient just does better if you remove it. And that when you very thoroughly remove all the disease, that’s when the patient does the best. And when you really excise a whole, like you de-peritonealize and excise the whole back of the pelvis and you leave a bunch of disease in the bowel wall, cause you’re afraid to do a bowel resection, it’s horrible. Like the bowel gets just glued in there. The endometriosis is inflammatory and it just glues in like.

cement and that patient is six months to two years from getting the colon intersection. You didn’t want to do the first place and it’s going to be way harder. Like when you go back, it’s going to be much harder and you’re probably going to take out more bowel than you would have in the first place. And so I am much more now just saying, you know what, let’s just do it. Like we’re able to do it. I’ve got great colleagues who are available to do it. And our patients just do well.

And I mean, they generally do really well and, and people just don’t do well as often when you kind of are afraid to do what needs to be done, in my opinion.

Ginger Garner PT, DPT (43:24)

Mm-hmm,

mm-hmm. So looking ahead, you know, I always ask this question of every clinician, therapist, surgeon is what advances or innovations in endometriosis care, you know, beyond excision surgery, et cetera, are you most excited about? It’s kind of a two-part question because, you know, we all like to look forward and see what advances may be on the horizon, but also given the current…

climate with women’s health and our political climate, cetera, you know, also what challenges do you foresee ahead as well?

Dr. Nicholas Fogelson (44:01)

Well, regarding the politics question, mean, hopefully not. know, mean, both across the aisle, there’s been interest in endometriosis. I don’t think endometriosis is a political issue, particularly, obviously abortion is a political issue, but I don’t feel like, like endometriosis has gotten wrapped up in that really. mean, you had Orrin Hatch and who is a democratic Senator who ran for president. I don’t know why I’m blanking our name, but kind of short reddish hair.

Ginger Garner PT, DPT (44:23)

Mm-hmm.

Dr. Nicholas Fogelson (44:31)

but, anyway, like Orin Hatch and I can’t remember her name.

Ginger Garner PT, DPT (44:36)

Elizabeth Warren was

involved at some point too, right? Elizabeth Warren? Yeah.

Dr. Nicholas Fogelson (44:39)

Who? Yeah, that’s who I’m, that’s exactly who I’m trying to

think of. So, Elizabeth Warren and Orrin Hatch co-authored a bill that was for endometriosis research because I think that they both had family members with endo and they’d had advocacy. I mean, that was across the aisle and Orrin Hatch is a disgustingly conservative Republican. I still love you if you’re Republicans, but I’m liberal, I’m sorry. But the, I.

Ginger Garner PT, DPT (44:48)

Mm-hmm.

you

Dr. Nicholas Fogelson (45:10)

so I don’t really feel politically. I’m not too worried about it. No, I mean, God knows. mean, every, every day we keep hearing things that are disturbing. So who knows? But, as far as what’s on the horizon, you know, I say every day, I would love to be put out of it, put out of a job, know, endometriosis, excision surgery is not scalable. took me 10 years of serious study to get really good at it. Like you can’t make enough endometriosis, excision, even if endometriosis, excision surgery were perfect, which it isn’t.

You can’t make enough endometriosis excision surgeons to serve everybody with endometriosis. It’s too difficult. and the, the economic system doesn’t want to pay people enough to, actually make a career out of it. And so you either have, you either have dabblers or you have specialists and the specialists usually don’t take insurance because the insurance won’t pay them enough. And

Ginger Garner PT, DPT (45:45)

Yeah.

Huge problem.

Dr. Nicholas Fogelson (46:03)

So we need to find ways to treat this disease other than surgery. Ideally, every disease is genetic. know, when they say like, how genetic is a disease? Well, every disease is genetic. Like everything that happens in the body is happening because of transcription of genes. And there can be external factors like bacterial infection and all kinds of stuff. But in the end, everything that happens is happening because of genetic stuff that’s happening, either genetic or epigenetic things that are occurring.

There’s a lot of genetics in endometriosis, which means that if people get interested enough in it, and they are, there will be genetic answers to endometriosis. Like there will be a time when we have understandings of certain genetic subtypes of endo, and we will be able to modify people’s genes or treat the gene products of some malformed gene and address endometriosis at its deep fundamental nature. Like when people say, I want to…

treat the fundamental nature by sizing endometriosis. I’m like, no, the fundamental nature would be fixing the genes that are causing endometriosis. Like that’s the real fundamental nature. And it’ll come, you know, I don’t know exactly when, but there’s a lot of private funding for that because obviously it would be a gold mine if somebody were to, you know, get some good therapeutics for that. And so there’s a lot of private funding of it’s in that direction. There are also kind of middle of the road.

Ginger Garner PT, DPT (47:03)

Yeah, yeah, what’s the phenotype? Yeah.

Dr. Nicholas Fogelson (47:24)

approaches. So we have kind of the traditional approaches of hormonal suppression, whether it be birth control pills or Lupron or Elissa. And those things have some efficacy and they have downsides as well. But then you have sort of these middle of the road anti-inflammatory pathways, like interest in whether or not, like IL-6 has a impact in the endometriosis inflammatory cascade. will maybe IL-6 suppression can be helpful? There’s a whole bunch of drugs out there that are right now being used for

eczema and they’re being used for Crohn’s disease, like, Humira and, and, you know, you name, you name the ad that you see while you’re watching Jeopardy. like these are all very expensive, but very effective drugs for chronic inflammatory conditions. it’s entirely possible that those things would have some efficacy in endometriosis because they are, they are affecting the immune system in a way that is going to.

decrease, like if we can identify like what is the predominant immune activity that’s leading to the inflammation of endometriosis, if you can selectively suppress that part of the immune system, that might be a good. And so there’s research in that. I mean, if it happens, it’ll bankrupt the medical system because those drugs, endo is so common and those drugs are so expensive, but the drugs will get cheaper over time. So there’s a lot of, there’s stuff out there and it’s going to change over time, you know.

Ginger Garner PT, DPT (48:45)

Thank

Dr. Nicholas Fogelson (48:52)

But I don’t know how soon, like I’m almost 50 now. You by the time I’m 60, I bet there will be significant, there’ll probably be some significant therapeutics that weren’t available now. And maybe by the time I’m 70, there might even be some genetic stuff. I know a geneticist that was saying that in five years we’re going to have this disease kick because he was on, he thought he was had the tiger by the tail, but that didn’t end up being true.

Ginger Garner PT, DPT (48:54)

Yeah.

Yeah, yeah, it is gonna be a while. I’m the same age and I think it will be, you know, 10 or 20 years, but that’s why I was excited to do this entire season on Endo because there is so many amazing things from whether it is mental health and, you well-being because after they leave your office, they usually come to our office, they come to pelvic floor PT and they talk to a mental health therapist about

Dr. Nicholas Fogelson (49:39)

Yeah.

Ginger Garner PT, DPT (49:42)

even the medical gaslighting and the trauma that happens with the dismissal and the delay in diagnosis and all those things that we cover. So there is a lot of hope.

Dr. Nicholas Fogelson (49:51)

It’s a, it’s a big part of me and some patients that like being told that they have endo, you know, usually if you come out of the operating room and you’re told that you have the disease state, you’re like, gosh, you, when someone’s having pelvic pain and they’re, and they come out and you said, yep, had endometriosis, they’re, they’re validated and they’re happy. Like if you ask it, an endometriosis patient, what do they fear the most? It’s being told that you didn’t find anything, you know? And it’s like the worst thing you can tell a patient after surgery is I didn’t find anything because they’re painful. Like they want.

Ginger Garner PT, DPT (50:14)

Yeah, yeah, that’s true.

Mm-hmm.

Dr. Nicholas Fogelson (50:21)

there to be an answer.

Ginger Garner PT, DPT (50:22)

I went through that feeling the same way when I went through mine of not wanting it to be that, but also knowing, it kind of has to be that at the same time, which it was.

Dr. Nicholas Fogelson (50:33)

Right. And it’s

funny how kind of poorly people, a lot of people still have a lot of experience with proper diagnosis. I mean, I’ve had patients that had five, six, seven different people look at them and they’ve had lots of pelvic exams. And then I examine them and they have like a grossly abnormal pelvic exam with big nodules of endometriosis behind the cervix. And it’s like you touch it with your finger and the patient’s extremely painful and it’s hard and it’s nodular. It’s like, well, that’s deep infiltrating endometriosis. Like I have to go in my mind like,

What the hell do you think this is? Like, do you think it’s normal that there’s this hard knot behind their cervix that is exquisitely painful? It’s almost like they’re doing a pelvic exam just to put on the paper that they did a pelvic exam. Like, they’re not actually examining the patient. And I understand, like, when people are asked to being seen 25 patients a day and they’re just trying to blur through annual exams, it’s almost like the exam is just a rote activity. It’s not like they’re actually engaging their brain in examining the patient.

Ginger Garner PT, DPT (51:30)

Yeah.

Dr. Nicholas Fogelson (51:31)

So I kind of shake my head. Like I have patients, I had a patient, I don’t know about a month ago that she’d had many, many, many normal public exams by board certified OBG WANS. And she had a lesion that was fungating, eating its way through the back of her vagina. And she’d been having horrible pain and people say their exams normal. And I’m like, what the F are you talking about? Like there’s a big knot of endometriosis. It’s not even that you can feel it. You can put a speculum in there and you can see it. And it’s like, what the f*ck do you think that is? Like.

Ginger Garner PT, DPT (51:45)

Mm.

Yeah.

Yeah.

Dr. Nicholas Fogelson (52:00)

Excuse me, don’t want to, you may have to bleep me and you don’t get a.

Ginger Garner PT, DPT (52:02)

We can swear.

We can swear. Endometriosis does require that.

Dr. Nicholas Fogelson (52:07)

And so,

and you know, and that kind of disease is very treatable. I mean, that patient might need a big surgery, but she’s going to get way better when we do that surgery. Like that, that’s the patient I really want to see. The patient that has a few lesions scattered around. First of all, lots of people can do that surgery well and be that surgery actually is not going to make as big of a difference for her as someone that has just big gnarly disease that we can really.

Ginger Garner PT, DPT (52:17)

Yeah.

Dr. Nicholas Fogelson (52:34)

really make a huge difference on this. That surgery is gonna be transformative. But also a long road, like that surgery, I think that a lot of times we focus on, we’re gonna fix this problem when all we can do is prepare the body to heal. Like we can remove the offending thing that is really a problem and try to get everything put back together with as healthy tissue as possible. And then the patient has to heal. And that healing can take.

months to years, you know, it’s not overnight and it’s not a continuous path towards better either. The bigger the surgery is, the more kind of up and down things go and there’ll be a of times they’ll feel way better right away, but then they’ll just be ups and downs. And you know, as you see your patients in post-surgery, I’m sure that, you know, patients are better one week and worse the next week and all kinds of stuff. So.

Ginger Garner PT, DPT (53:23)

Yeah, yeah, it’s

what we try to control for all of the other things like the epigenetic pieces of that, of how they manage stress and the quality of their sleep and how they’re responding, you know, both visceral from a visceral perspective and a somatic perspective because there’s so many things that go into it.

Dr. Nicholas Fogelson (53:42)

Yeah. And it’s not

like when someone says, pain’s in your head. I’m like, yep, it is in a way. mean, pain is a neurologic, pain is a, pain is a neurologic phenomenon. Like it is occurring in your brain. and the entire system is the entire, I mean, you’re not making it up, but it is, it is a neurologic phenomenon and the entire system works together and

Ginger Garner PT, DPT (53:48)

Yeah, yeah, technically.

Dr. Nicholas Fogelson (54:10)

If you are super stressed out and activated and, sorrowful about marriage or, or, whatever, your body doesn’t know how to compartmentalize that. Like you are going to perceive pain more and not, that doesn’t mean that you’re crazy. This is the way the nervous system works. You know, you, you, if you’re happier, you will perceive pain less period. And that can mean that you just.

played sports and you enjoyed yourself. can mean that you had a great conversation with a friend or you read a good book. these kinds of things are not blowing the patient off and saying, go read a book. It’s like, no, find things that you like to do in your life and enjoy it. You will actually have a better life and you will feel less pain literally. Like. Not. And again, that’s not just blowing people off and saying, we don’t want to do surgery. saying like all of these things go together. and you know, I.

I love it when my patients have a psychotherapist because pain sucks and they need to talk about this stuff and they have all the other sh*t in their life that everyone else has. Most people would benefit from therapy at certain times in their life. And I always say that pain is neurologic, but suffering is psychological. know? And I think for everybody at a certain level of intensity, pain is suffering. you can’t, unless you’re just like some ridiculously trained Buddhist monk, like you can’t…

Ginger Garner PT, DPT (55:12)

Yeah.

Dr. Nicholas Fogelson (55:33)

certain kinds of pain without feeling incredible suffering. But there is a certain training, like how did that Buddhist monk be able to tolerate ridiculous pain and not suffer? Because they do, they learn. That’s a really rigorous training, but anybody can learn a certain amount of training that allows them to suffer less.

Ginger Garner PT, DPT (55:36)

Yeah.

Right, because everything we do, I

mean, every time if you touch a patient, talk to the patient, whatever you’re doing, it changes their nervous system and everything has the potential to help them develop the skill set so that they can self-manage things.

Dr. Nicholas Fogelson (56:11)

Yeah.

And not, I, I hate it. was a hate of it. I, I don’t want patients to be in the point of view that like, I’m going to get back to my life when this thing is over, you know, I need to get this thing fixed so I can get back to my life. I’m like, none of this is your life right now. And, and you actually will do better if you get back to your life despite this, you know, and it may change. and I’m going to do surgery or we’re to do treatments and this stuff’s going to get better.

Ginger Garner PT, DPT (56:34)

Mm-hmm.

Dr. Nicholas Fogelson (56:40)

but it’s going to get from eight out of 10 to three out of 10. It’s not going to get from eight out of 10 to zero. You know, and if you, and if you put being at zero before you’re to get back to your life, you may never get back to it. And, and so, and, getting back to your life as part of feeling better too, that, that, you know, Mark Possever, my, my mentor with neuro-pelviology always said that the brain gets really good at whatever you do. And if what you do is you experience pain and you don’t distract it with anything else,

It will get very good at feeling pain, you know, and, and getting your brain to focus on other things, whether that be whatever it is, painting or, or your work or whatever it is you’re passionate about that you’re not just trying not to pay attention to the fact it hurts. Like you are making it hurt less because you were getting your brain to engage itself in something else. And so, um,

Ginger Garner PT, DPT (57:34)

Yeah,

thank goodness for neural plasticity. And our brains can grow and change and do those things. yeah, yeah, we can take it both directions.

Dr. Nicholas Fogelson (57:38)

Yeah. In good ways and in bad ways, you know, and when people talk about, you know, central sensitization, that’s

it’s not BS. I, I, I, it irritates me when people say that central sensitization is just something that people use to gaslight endometriosis patients. like, no, no, this is an actual neurologic phenomenon. It’s studyable. can, you can observe it in animal studies and in humans. Like this happens, you know? And so.

But again, it’s like what you’re saying. It’s kind of a negative neuroplasticity where, you know, if you go and hit a zillion golf balls, you’re going to develop a pathway for how to swing a club, good or bad. But, you know, and if you feel a lot of pain, you’re going to unfortunately develop a pathway for feeling pain. And that’s kind of what sensual sensitization is.

Ginger Garner PT, DPT (58:18)

Yeah.

Yeah, at the end of the day, I end up telling my patients that,

Actually the vast majority of what I end up doing, whether I’m using yoga or Pilates or mindfulness or whatever it is, is repatterning. It’s just repatterning what they come in with to say, okay, we need a different pathway or whether it’s the pelvic floor getting unplugged from the core or whatever it may be, it’s just finding a new pathway for them to settle into.

and bring alongside that endo diagnosis into their activity, whether it’s they wanna get back to horseback riding or just walking their dog, whatever it may be. But it’s a lot of, if you could reduce it down, it’s just repatterning for the brain.

Dr. Nicholas Fogelson (59:14)

And I think

that’s part of how important PT is for our patients because it’s not just whatever you’re doing physically. And in fact, what you’re doing physically may be less important than just the spending of an hour with someone or 45 minutes with someone. And inevitably you’re talking and it is a, you know, really being heard and being present for their problem that they’re having. And, you know, I try to spend as much time with patients as I can, but I think that PT’s are providing a different sort of support.

And usually they’re women too, and I’m not. And I think that that, I think it’s just really helpful. So I always encourage people to develop that relationship.

Ginger Garner PT, DPT (59:55)

Yeah, at the end of the day, we’re human beings and we’re built for relationship and not this isolated independence. And endometriosis is absolutely a disease where we need the whole team. The proverb of, know, it taking a village is so true. So I just want to thank you for your time, for being a part of that village, for bringing your unique expertise and care.

Thank goodness, you mentioned being able to focus like that, however we identify that, think for some people that’s that autism spectrum label or whatever it may be, but I think that is part of the brilliance of the human brain too.

Dr. Nicholas Fogelson (1:00:41)

I’m not formally

diagnosed by any mental health provider, but if I take any those online quizzes, I blow the top off. I blow the top off it. So I’m like, that makes sense.

Ginger Garner PT, DPT (1:00:44)

Yeah, yeah, it feels like it.

I think that’s part of where the brilliance of the human brain, I have multiple family members that are on the spectrum and they are so incredible in so many ways. And so I think that that’s just part of the human brain that we don’t fully understand is how people experience the world around us and can do amazing things. So.

Thank you so much for spending time, especially after your complex case today that you had. And y’all, y’all don’t know this, but that’s what he came from, is he finished up a really hard case. He did refer to it during the podcast, so you might remember that. But just to come out of that and then come right into this. Thank you, that’s generous, it’s gracious. I really appreciate you, thank you.

Dr. Nicholas Fogelson (1:01:35)

Yeah. And, and I never want to take anywhere near complete credit. My, my colleague, Jeff Watkins, who’s my thoracic surgeon did quite a lot of that. And I watched him do a bunch of it, but it’s funny. Like when you’re in. When we’re in the OR working, whether we’re the one working or our colleagues working and we’re watching them, it’s, all kind of like intellectually tiring. So it’s not physically tiring. It’s just kind of like a little exhausting, but, but I’m happy to do it. think that patient will do well.

Ginger Garner PT, DPT (1:01:45)

you

Yes. Yeah.

I’m sure, I’m I’m sure he’s got a great team.

Dr. Nicholas Fogelson (1:02:06)

Yeah, we do. We’re fortunate.

Ginger Garner PT, DPT (1:02:09)

Thank you so much for joining me again.

Dr. Nicholas Fogelson (1:02:10)

Thanks.

And certainly if anyone’s listening is interested in contacting me, if you go to nwendometriosis.com, we can do free case reviews. And in the US, we charge a little bit for international case reviews, mostly just because if people aren’t serious about coming, it’s hard to spend too much time. And sometimes that’s a little bit of a screening about whether or not someone actually wants to come and see us.

Ginger Garner PT, DPT (1:02:37)

and

on Instagram as well. Give them a follow.

Dr. Nicholas Fogelson (1:02:39)

Yes.

And it’s just Nick at Nicholas Fogelson on Instagram. And my partner Shanti Mohling is like 10 times as many followers as I do. So I need to catch up. So come on. Like and subscribe. I don’t post it. I need to post.

Ginger Garner PT, DPT (1:02:43)

on Instagram.

Yeah, that’s right.

Like you have time for that. my God, go do some Lego instead, right? When you’ve got free time. But all right, you guys give Dr. Fogelson a follow and do check out their website, nwendometriosis.com. Thank you.

Dr. Nicholas Fogelson (1:02:55)

That’s the problem.

Yeah. Yeah. Yeah.

Yeah.

Thank you so much. Great.